Cognitive Therapy of Chronic Pain
by Carrie L. Winterowd, Ph.D., Aaron T. Beck, M.D. and Daniel Gruener, M.D.
What is Chronic Pain?
Everyone has been in pain at some point in his or her life. However, unrelieved chronic pain is perhaps one of the most challenging problems faced by patients as well as practitioners and providers. Pain is an “unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage” (Merskey & Bogduk, 1994). Chronic pain is pain that persists beyond the time one would expect normal healing to occur (Bonica, 1953; as cited in Merskey & Bogduk, 1994).
How our thoughts, feelings, and actions affect our pain
When the pain signal is experienced and processed in the brain, certain thoughts, memories and emotions may be activated. So, when a person experiences a pain sensation, s/he will have some emotional response(s) to it and will experience certain thoughts and/or images during or immediately following the pain. Similarly, thoughts and emotions that are activated in the brain may also affect the pain signal. In other words, our thoughts, memories, and emotions can influence the experience of pain physiologically.
For example, a chronic pain patient named Phil experiences burning, numbing sensations in his lower back and legs. He feels frustrated and sad, and thinks, “This pain is horrible. I cannot handle it. This is so unbearable. I cannot go on like this.” Next, Phil imagines the pain taking over his whole body. His pain worsens. He becomes even more absorbed in his pain, frustration, and sadness. He decides to go back to sleep to escape from this pain. Why is Phil feeling horrible? It isn’t simply because he is experiencing severe pain. It is, in part, because of what he is telling himself about the pain—in other words, the meaning he has given his pain. Phil has interpreted his pain as being “uncontrollable” and “unmanageable.” He thinks of himself as a victim—powerless to stop his pain. His negative thoughts start taking on a life of their own.
Conversely, another chronic pain patient named Karla experienced burning and numbing pain sensations in her lower back and legs. She thinks, “Here comes that pain again. Okay. I know it’s going to hurt. So, what can I do? I need to catch my breath and focus on something else if I can. It’s really hurting. (pause) I have to remember that it will eventually subside in the next hour if I take steps to manage it. I have to focus on relaxing my body and moving through the pain by focusing on something else. It’s not time yet for my next pain pill. So I will have to wait.” Karla exhibits more realistic and helpful thoughts about her pain compared to Phil, the patient in the previous example. While, indeed, Karla is experiencing significant levels of pain, just like Phil, she is choosing to think differently about her pain. She realizes that her pain is hurting. She knows how difficult it can be to “get through the pain.” However, Karla focuses on her efforts to cope with it. She reminds herself of what she can do to manage her pain (e.g., relax, distract). She remembers that her pain has subsided in the past and that it won’t last forever. The way Karla thinks about her pain will help her focus less on her physical suffering and more on her efforts to cope. Karla will be less prone to negative emotions (emotional suffering) compared to Phil because of the meaning she has given to her pain—that she has some ability to cope with it and that the duration of her pain is typically time-limited. She feels more in charge of her pain and of her life because she is thinking more realistically about her pain.
In summary, our negative, unrealistic thoughts about pain and other life events can have a significant and negative impact on how we perceive pain sensations, how we feel emotionally, and what we do when we are in pain. When we think negatively, we are more likely to feel emotionally distressed, which can result in 1) muscle tension, making the pain even worse, and 2) a hyper-aroused state in our nervous system, activating more pain messages in our bodies, leading to more pain. When we think negatively, we are also more likely to engage in self-defeating behaviors (e.g., inactivity, social isolation, over reliance on pain medication), which can also affect our pain. Often times, the thoughts and images we have about our pain and life events in the moment are related to underlying beliefs. Most people who have chronic pain have beliefs about their pain (i.e., “The pain has taken over my life.”), themselves (“My pain makes me a weak person.”) and their bodies (e.g., “My body is broken.”), their relationships with others (“My doctors don’t care about my pain,” “No one understands what I am going through,”), and about their future (“I am doomed to be pain-ridden forever.”).
Cognitive Therapy with Chronic Pain patients
Cognitive therapy addresses the importance of realistic, healthy beliefs, attitudes, and behaviors in reducing the emotional and physical suffering associated with pain. Cognitive therapy is geared toward identifying any emotional, cognitive, behavioral, physiological, and/or environmental (e.g., family, social, cultural, and societal) difficulties that might be influencing the experience of pain. Although it is rare for clients to become pain free, cognitive therapy teaches people how reduce their pain, how to be less affected by their pain, and enhance their functioning in various life roles.
Therapists typically conduct a thorough intake interview prior to the start of therapy, to obtain a clear picture of the person’s presenting problems and history, including a thorough assessment of his or her pain (including its location, duration, intensity, frequency, fluctuations, the client’s descriptions of it, “triggers” and “alleviators” [what makes the pain worse or better], the client’s emotions, thoughts, and behaviors when in pain, personal coping efforts, the associated physical limitations and other consequences of pain [e.g., role limitations, financial and/or legal difficulties], other psychosocial stressors that affect pain [e.g., personality, relationship issues, environment], medical/health care history including how the pain condition developed, types of treatments received for pain, pain medications prescribed).
Therapy sessions focus on helping clients learn to cope with their pain and their lives by learning: (1) to think more realistically about their pain and other life events, (2) to relax more effectively than before (by using deep breathing techniques and relaxation exercises), (3) to manage their activities given their pain, (4) to communicate in an assertive manner with others including their physicians, family members and friends about their pain, and (4) to solve problems related to their pain and other life stresses. The course of cognitive-behavioral therapy typically starts with a focus on pain management, and then moves to other concerns or issues (assuming pain management is the primary goal of therapy). The primary target for change is clients’ negative, unrealistic thoughts, images, and beliefs about their pain, the consequences of having pain, and other life stresses. Cognitive therapists also help clients identify behaviors that exacerbate pain and stress and teach clients new coping strategies as well as adaptive, healthy behaviors. Most people can feel better after 12 cognitive therapy sessions.
People who seek cognitive therapy for pain management are often seeking medical care for their pain as well. As a result, many people are prescribed medications to assist with pain management. Medication is prescribed based on the diagnosis of the pain problem as well as the severity of pain experienced. For mild to moderate pain, most medical professionals prescribe non-opioid medications such as acetominophen, or non-steroidal anti-inflammatory drugs such as ibuprofen, or cox-2 inhibitors. If the patient continues to experience pain, a non-opioid–opioid combination of medication is considered next. The strength of a narcotic medication (i.e., opioids) is not as important as it was once thought, because addiction is comprised of psychological dependence as well as a physiological process. Therefore, many physicians prescribe opioids (i.e., schedule-2) to get chronic pain patients comfortable immediately. Adjuvant medications may also be prescribed as well. An adjuvant medication is one that has FDA approval for one area, but also has off-label uses in pain. For example, some antidepressants approved for the treatment of depression are also effective in treating neuropathic pain (based on pain research findings). The FDA has not approved it for this purpose, but they are often prescribed for such purposes because there is empirical and clinical evidence to support its use. If the patient is suffering from moderate to severe pain, many medical professionals prescribe opioids right away as well as adjuvant medications.
Cognitive therapy is an effective form of treatment for people who have chronic pain. There is firm evidence in the research literature that cognitive-behavioral treatments are effective in reducing clients’ pain levels, use of pain medications, negative thoughts, extent of physical disability as well as enhancing clients’ pain control, emotions, physical functioning, health status, and relationships with others compared to not being in therapy at all (Morley, Eccleston, & Williams, 1999, van Tulder et al., 2000). In addition, multidisciplinary pain treatment programs that incorporated cognitive-behavioral therapy and behavioral therapy approaches were significantly more successful than programs that used only one treatment or programs with no other treatments (Cutler et al., 1994; Flor, Fydrich, & Turk, 1992). Overall, it appears that the cognitive-behavioral approach has a positive effect when combined with active treatments such as medications, physical therapy, and medical treatments for chronic pain clients in treating pain, thoughts about pain, and pain behavior problems (Morley et al., 1999).
There are resources for readers who are interested in self-help books for chronic pain clients (e.g., Catalano & Hardin, 1996; Caudill, 2002; Jamison, 1996) or cognitive therapy books for chronic pain clients (e.g., Winterowd, Beck, & Gruener, 2003). There are also a number of professional organizations committed to the topic of chronic pain and pain treatments, such as the American Pain Society and the International Association for the Study of Pain.
References and Further Reading
Bonica, J. (1953). The management of pain. Phildelphia: Lea & Febiger.
Catalano, E., & Hardin, K. (1996). The chronic pain control workbook (2nd edition). Oakland: New Harbinger Publications, Inc.
Caudill, M. (2002). Managing pain before it manages you (revised edition). New York: The Guilford Press.
Cutler, R., Fishbain, D., Rosomoff, H., Abdel-Moty, E., Khalil, T., & Rosomoff, R. (1994). Does nonsurgical pain center treatment of chronic pain return patients to work? A review and meta-analysis of the literature. Spine, 19, 643-652.
Duckro, P., Richardson, W., & Marshall, J. (1995). Taking control of your headaches: How to get the treatment you need. New York, NY: The Guilford Press.
Flor, H., Fydrich, T., & Turk, D. (1992). Efficacy of multidisciplinary pain treatment centers: A meta-analytic review. Pain, 49, 221-230.
Gersh, W., Golden, W., & Robbins, D. (1997). Mind over malignancy: Living with cancer. Oakland, CA: New Harbinger.
Greenberger, D., & Padesky, C. (1995). Mind over mood: Change How You Feel By Changing The Way You Think. New York: The Guilford Press.
Jamison, R. (1996). Learning to master your chronic pain. Sarasota: Professional Resource Press.
Merskey, H., & Bogduk, N. (Eds.). (1994). Classification of chronic pain: Description of chronic pain syndromes and definition of pain terms. Seattle: IASP Press.
Morley, S., Eccleston, C., & Williams, A. (1999). Systematic review and meta-analysis of randomized controlled trials of cognitive behaviour therapy and behaviour therapy for chronic pain in adults, excluding headache. Pain, 80, 1-13.
Starlanyl, D., & Copeland, M. (1996). Fibromyalgia & chronic myofascial pain syndrome: A survival manual. Oakland, CA: New Harbinger.
Uppgaard, R. (1999). Taking control of TMJ: Your total wellness program for recovering from Temporomandibular Joint Pain, Whiplash, Fibromyalgia, and related disorders. Oakland, CA: New Harbinger.
van Tulder, M., Ostelo, R., Vlaeyen, J., Linton, S., Morley, S., & Assendelft, W. (2000). Behavioral treatment for chronic low back pain. Spine, 26, 270-281.
Winterowd, C., Beck, A., & Gruener, D. (2003). Cognitive therapy with chronic pain clients. New York: Springer Publishing Company.
Young, J., & Klosko, J. (1994). Reinventing your life. New York: Plume Books.
Note: Significant portions of this manuscript are excerpts from Winterowd, C., Beck, A., & Gruener, D. (2003). Cognitive therapy with chronic pain patients. New York: Springer Publishing Company. Copyright 2003 by Springer Publishing Company. Used with permission of Springer Publishing Company.